Welcome back to Open Minded Health Promotion! This week is all about how cisgender women who have sex with women, including lesbian and bisexual women, can maximize their health. As a reminder — these are all in addition to health promotion activities that apply to most people, like colon cancer screening at age 50.

All cisgender women who have sex with women should consider…

Talk with their physician about their physical and mental health

Practice safer sex where possible to prevent pregnancy and sexually transmitted infections. Some sexually transmitted infections can be passed between women. If sexual toys are shared, consider using barriers or cleaning them between uses.

If under the age of 26, get the HPV vaccine. This will reduce the chance for cervical, vaginal, anal, and oral cancers.

Avoid tobacco, limit alcohol, and limit/avoid other drugs. If you choose to use substances and are unwilling to stop, consider using them in the safest ways possible. For example, consider vaporizing marijuana instead of smoking, or participate in a clean needle program.

Maintain a healthy weight. Women who have sex with women are more likely to be overweight than their heterosexual peers. Being overweight is associated with heart disease and a lower quality of life.

Exercise regularly. Weight bearing exercise, like walking and running, is best for bone health. But anything that gets your heart rate up and gets you moving is good for your body and mind!

Seek help if you’re struggling with self injury, anorexia, or bulimia. These issues are much more common in women than in men, and can be particularly challenging to deal with.

Cervical cancer screening/Pap smear. All women with a cervix, starting at age 21, should get a pap smear every 3-5 years at minimum. Human papilloma virus (HPV) testing may also be included. More frequent pap smears may be recommended if one comes back positive or abnormal.

Pregnancy testing, even if you have not had contact with semen. Emergency situations are where testing is most likely to be urged. Physicians are, to some extent, trained to assume a cisgender woman is pregnant until proven otherwise. If you feel strongly that you do not want to get tested, please discuss this with your physician.

BRCA screening to determine your breast cancer risk, if breast cancer runs in your family. They may wish to perform other genetic testing as well, and may refer you to a geneticist.

If you’re between the ages of 50 and 74, mammography every other year is recommended. Mammography is a screening test for breast cancer. Breast self exams are no longer recommended.

One note on sexually transmitted infections… some lesbian and bisexual women may feel that they are not at risk for sexually transmitted infections because they don’t have contact with men. This is simply not true. The specific STIs are different, but there are still serious infections that can be spread from cis woman to cis woman. Infections that cis lesbians and bisexual women are at risk for include: chlamydia, herpes, HPV, pubic lice, trichomoniasis, and bacterial vaginosis (Source). Other infections such as gonorrhea, HIV, and syphilis are less likely but could still be spread. Please play safe and seek treatment if you are exposed or having symptoms.

Data from a University of Maryland School of Medicine survey were just released showing that nearly four out of ten lesbians do not get regular pap smears. Pap smears screen for cervical cancer, among other things. Cervical cancer is usually caused by the human papilloma virus (HPV). HPV can be spread by skin-to-skin contact, so lesbians are just as much at risk for getting HPV as bisexual or heterosexual women. Screening is important to detect precancerous changes and cancer in their earliest stages so that treatment can be done when it’s most effective, preventing deaths.

Why do so few lesbians get their screenings? The primary reasons cited in the survey were: a) not having a physician referral, and b) not having a physician. Together, these two reasons account for 34.8% of study participants. We already know that lack of access to care is a big problem in gender and sexual minority communities. This just helps to confirm it. The survey authors note that lesbians who were open with their physicians about their sexual orientation were more likely to be screened than those who weren’t open.

There has been a recent change to pap smear recommendations. Pap smears are no longer recommended every year for most people. Screening starts at 3 years after first sexual activity, or age 21, whichever is first. From age 21-30, screen every 3 years, then from age 30-65, screen and do an HPV test every 5 years. After 65, no screening is recommended. If a pap smear is abnormal, screenings become more frequent. I should also note that these guidelines apply to everyone with a cervix, regardless of gender identity.

I, personally, think it’s highly advisable for everyone to know their HPV status and get vaccinated if possible, in addition to regular pap smears. HPV vaccines are not a replacement for pap smears because they don’t vaccinate for all HPV strains which cause cervical cancer. However, vaccines do protect against some.

EDIT (10/21/2012): I should also note that during a pap smear, a physician can do other screenings. This includes gonorrhea/chlamydia screening, looking for signs of other STDs or vaginal cancer, and checking the ovaries for lumps.

How does a bacterium like gonorrhea become antibiotic resistant? It’s evolution. All bacteria are slightly different because of random mutations in their genes. Antibiotics don’t always kill all the bacteria in an infection. Some of them are naturally resistant to the antibiotic. Those bacteria then can reproduce. Over time and repeated applications, the resistant bacteria become the common kind. And then we have a problem.

Gonorrhea can cause some really nasty long-term damage. It can cause sterility for both sexes (through either pelvic inflammatory disease or inflammation of the epididymis). It can also spread to infect joints, causing arthritis, or into the blood, which could be fatal. Gonorrhea can also be transmitted to newborns in the process of a vaginal birth. In newborns, it can cause blindness. All gonorrhea infections should be treated.

Since all infections should be treated, the best way to deal with the rise in antibiotic resistance to gonorrhea is to prevent infections.

What are the symptoms of gonorrhea? First, it’s important to know that it’s possible to have gonorrhea without symptoms. Around 90% of women and 10% of men with gonorrhea don’t have symptoms. Symptoms of a genital infection include a) a burning feeling while peeing, b) white, yellow, or green discharge from a penis and c) bleeding between periods. An anal infection may itch or burn, cause painful bowl movements, or create a discharge. Throat infections generally only cause a sore throat. Symptoms can appear up to two weeks after the infection starts.

Gonorrhea spreads by fluid contact, so vaginal, oral, and anal sex can all spread it. A simple skin-to-skin contact won’t spread it, unlike HPV. Like all STDs, the only way to 100% prevent it is to never have sexual contact with other people. That’s usually not possible. The next best thing? a) use barriers (like condoms, latex or nitrile gloves, or dental dams) correctly and consistently with all toys and body parts that come in contact with genitals, b) get yourself and your partner(s) regularly tested, especially before having sexual contact with a new person, c) restrict the number of people you choose to have unprotected sex with.

Time for another post on prevention. This time we’re looking at skin self-exams (SSEs)

SSEs are performed to check for early-stage skin cancer. It’s best to perform them monthly. The time of month generally doesn’t matter. A skin self exam can be done by anyone with skin… which should be everyone. People who definitely should consider doing SSEs because they are at higher risk for skin cancer include those:

With skin cancer in the family (especially melanoma).

With many moles or freckles

Who burn instead of tan

Are fair-skinned or fair-haired

Who live at elevation or in the tropics

Spend a lot of time outdoors

Are immuno-compromised or have an autoimmune disorder

Take certain medications including: birth control pills, some antibiotics including tetracycline and sulfa drugs, NSAIDs such as Aleve and Ibuprofen, and tricyclic antidepressants.

Your doctor should check your skin during your yearly check-up. There are official instructions for SSEs available on the ACS website, but here’s the essence: look at your skin everywhere. They really do mean everywhere, even your scalp and under your nails! A full-length mirror is essential. A hand-mirror is really handy if you don’t have an extra pair of eyes. Like with breast and testicular self-exams, a partner or partners can help and the exam can become part of other activities. Mole maps, like this one (PDF), are available to help you keep track of changes.

When checking your skin, take a close look at your moles. You want to watch out for moles that are:

Asymmetrical: It’s not the same on both sides.

Border irregular: The border is irregular or ragged….like an amoeba instead of a circle.

Color variation: The color is different in different parts of the mole.

Diameter is larger than a pencil eraser.

Evolving: The mole is changing.

Other warning signs are also possible. If you spot something weird, you want to talk to a doctor ASAP. It may not be skin cancer, but you don’t want to risk it and some skin cancers can move very quickly.

The American Cancer Society currently has no recommendations regarding testicular self exams – they say there aren’t enough data regarding their effectiveness. Some doctors, however, still recommend monthly self exams starting around age 14. Like breast exams, they:

Are a great way to get to know your body (especially for those of you who are going through body changes, or haven’t learned your body)! You’re better able to catch any changes, which you can then discuss with your doctor. Partner(s) can also be involved in exams, which can help keep them from getting boring.

Can lead to false positives (thinking that there’s something seriously wrong when there isn’t), which can be stressful and costly, and false negatives (thinking there’s nothing wrong when there is), which can be fatal.

Anyone with balls (testicles) can do a TSE — anyone else must examine someone else’s. Women, transmen, and anyone who has had an ochiectomy don’t have to do TSEs because they don’t have balls – they’re not at risk for testicle-related problems. Folks who are on the receiving end of cock and ball torture (warning!: graphic images) may especially wish to do TSEs to monitor for changes.

The timing of a TSE is not especially important. Some physicians say it should be monthly, but there isn’t a consensus that I’m aware of. Pick a day at a regular interval and stick to it!

How to do a TSE:

It’s best to do a TSE right after (or during) a warm bath or shower. The warmth relaxes the skin of the scrotum, making it easier to feel the inside bits (there’s no thickly bunched wrinkly skin in the way!).

Using both hands, gently feel one testicle at a time. Roll it between your fingers – how does it feel? Any unusual lumps or bumps? Does it feel different than usual, or does it hurt? Make sure you feel all of both testicles.

Take a look at the skin of your scrotum. Any unusual bumps or swelling?

The scrotum usually contains two testicles, plus a bunch of blood vessels and nerves (which you might be able to feel). Each testicle has an epididymus and a ductus deferens (aka vas deferens). The epididymus is a highly coiled tube-like structure that sits on the top and back of the testicle. The ductus deferens is also a tube, going from the epididymus up into the body, where it eventually connects with the urethra.

Testicles make sperm. The sperm enter the epididymus, where they’re stored and finish developing. During ejaculation, the sperm go whizzing out of the epididymus into the ductus deferens, into the urethra, and out the tip of the penis (along with other fluids that are added along the way).

It’s perfectly normal for testicles to be different sizes or to hang at different heights.

If you need help figuring out what’s what, and what’s normal, ask your doctor.

If you find something during a TSE, don’t panic. It probably isn’t cancer. There are lot of other things it could be – some potentially bad, others not so much. You do need to mention it to your doctor just in case.

What is Open Minded Health?

OMH is dedicated to providing information about gender and sexual minority health. Posts are a mix of the latest research, activity risk reduction tips, and the latest news.

This blog is definitely not suitable for children, and probably not work safe. It contains descriptions of sexual activities that may disturb some readers.

Also please be aware: I am not a doctor. OMH does not provide health care advice - the information here is to be used as information only. It does not substitute a visit to your health care provider. When in doubt, please ask your health care provider.

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